During initial meetings in April between PURE, the Minister of Health, and local stakeholders, diagnostic imaging was identified as a major priority of the health system in Zanzibar, a chain of islands of the coast of Tanzania. Now, four months later, Dr. Abiola Fasina, a fellow in emergency ultrasound from the University of Pennsylvania, is in Zanzibar working with PURE, the Zanzibar Ministry of Health and ZADIA, the Zanzibar Diaspora Association. Below is her report:

“Hello from the Spice Islands! So far I’ve visited the main referral hospital on Unguja Island, Mnazi Moja, which is located right near Stone Town. I’m exploring current limitations to ultrasound use here as well as possible future directions for training through discussions with various medical staff members. Last week, I had the opportunity to visit Zanzibar’s second main island of Pemba to assess 5 rural hospitals. It is an exciting time on Pemba Island as both the hospital at Micheweni and Mkoani are to become district hospitals by next year. This means improved access to specialist care and new additions or improvements to their physical space. The theme emerging from my assessment so far is an acute need for ultrasound in the care of obstetric and trauma patients in particular.

This week, I’ll visit the 2 district hospitals here on Unguja Island and then met again with local stakeholders and ministry of health staff. The government of Zanzibar and local staff are really keen on getting this program off the ground and providing improved care and service to their patients.”

PURE and our partners in Zanzibar are seeking funding to execute a locally relevant ultrasound training program by early 2016. Please contact us if you are interested in getting involved!

Three physicians from the PURE team arrived in Liberia last week launching a longitudinal point-of-care ultrasound training program for all resident physicians. Working with the Liberian College of Physicians and Surgeons and the Academic Consortium Combatting Ebola (ACCEL), PURE is leading this health system strengthening effort to advance the skills of local physicians in the realm of diagnostic and procedural ultrasound capacity at the point-of-care.

On Wednesday, we drove 4 hours from the capital to Bong County where we began working with a group 4 obstetric-gynecology 2nd year residents, 3 pediatric 2nd year residents, and 3 medical officers. Dr. Trish Henwood introduced the concept of point-of-care ultrasound and Dr. Raja Rao followed up with a lecture on physics and knobology. A few minutes into the small-group practical session as we played with depth and gain on the machines, a resident asked Dr. Raja to consult on a puzzling case. There was a pregnant woman on the OB ward who presented with a reported 12-week gestation with abdominal pain and a concerning mass. Dr. Raja helped determine the mass was actually the uterine fundus with a thickened endometrium, and the live 12-week fetus was actually an ectopic pregnancy! The patient’s vital signs were becoming suggestive of early hemorrhagic shock and the FAST ultrasound findings showed new significant free fluid compared with their earlier assessment confirming the diagnosis: life-threatening ruptured ectopic pregnancy. As Dr. Raja returned to the conference room to oversee as the trainees practiced FAST exams on one another, the patient was rushed to the operating room and survived.

The next two days were packed with practice. The OB-GYN residents lined up a series of pregnant patients and took turns scanning and looking over each other’s shoulders to discuss the findings. One woman reported that this baby was bigger than her other babies. The ultrasound finding? → Twins at 35 weeks gestation!
Dr. Trish broke off to oversee a resident scan another pregnant woman with a similar history. The diagnosis? → Triplets at 33 weeks gestation!

The pediatric residents identified a child with 2 months of right leg swelling and a recent refusal to walk. Her right thigh and right knee were swollen without erythema or warmth. The laboratory has no ability to run a complete blood count or inflammatory markers. An x-ray had been scheduled. Her point-of-care ultrasound showed an irregular bone cortex from mid-femur to the metaphysis with fluid surrounding her bone, fluid in her hip joint and fluid in her knee. Large lymph nodes were identified in her groin. The diagnosis? → Concern for septic arthritis of the hip and knee and osteomyelitis of the femur. The next day we obtained her x-ray which showed a moth-eaten femur supporting our findings. The pediatric team has contacted the orthopaedic surgeon to arrange further management.

This coming week we look forward to evaluating the baseline ultrasound skills of all of the first year resident physicians as we launch the training program in Monrovia.
Stay tuned for more updates!
– Dr. Alexandra Vinograd

The PURE team has returned to southwestern Uganda during an uncharacteristically sunny April to continue our ongoing ultrasound capacity-building at Mbarara University of Science and Technology. Following a series of meetings and planning sessions in Kigali, Rwanda our team of four trainers, led by PURE founder and lead trainer, Dr. Trish Henwood, crossed the verdant jungle border to join Drs. Derek Harborne, Julius Mugisha and Lisa Bebell at the Mbarara Regional Referral Hospital (MRRH).

After a brief celebratory reunion, we set to work, preparing for 2 days of intensive, multidisciplinary ultrasound seminars. Within a frenetic 24 hours we’d managed to wrangle a projector, a reliable generator in case of outages, training space in the surgical skills center, a catered lunch for our eager trainees, and volunteer models for practice scanning. The speed and success of our preparations were no doubt thanks to the hard work done by Drs. Bebell and Harborne in anticipation of our arrival.

We spent our first day with the MRRH obstetrics and gynecology department, a dedicated group of doctors, nurses, and midwives with whom PURE has worked before. ‘Enthusiastic’ doesn’t begin to describe our reception by the department. The audience of 25 was more than double our expectation, thanks, no doubt, to the usefulness and popularity of PURE’s prior training endeavors! Lectures provided by myself, Dr. Brian Cone, Dr. Alissa Genthon, and Dr. Julius Mugisha were punctuated by two lengthy, hands-on scanning sessions with volunteer patients from the obstetrics ward.

We spent day 2 with our already ultrasound-savvy ‘local champions’ from the medicine and surgery departments reviewing key topics in point of care ultrasound (DVT, soft tissue, IVC assessment for volume status). Later, Dr. Alissa Genthon introduced a new application to our trainees, the FASH exam (focused assessment with sonography for HIV-associated TB) pioneered by Dr. Tom Heller. The remainder of our second seminar day was spent practicing scans on each other before marching out to the wards to again supervise scanning on volunteer patients.

The conclusion of our seminar days was bittersweet. While training was a resounding, well-attended, and happy success our team parted ways shortly thereafter. Drs. Henwood and Genthon headed back to Rwanda to continue our ongoing training at CHUK in Kigali, while Dr. Brian Cone and I will remain here at MRRH for the next several weeks, providing ongoing bedside teaching, supervision, and spreading the gel-y ultrasound gospel with our champions in OB, surgery, medicine and pediatrics! Stay tuned for more updates in the weeks to come.

Prior to project kick-off in September 2014, a PURE-led needs assessment in early 2014 demonstrated that clinicians from the Obstetrics-Gynecology and Emergency wards could benefit most from immediate training and access to point-of-care ultrasound. To that end, clinicians were elected by local leadership from the surgical, medicine, pediatrics and ob-gyn departments. Clinicians learned to utilize bedside ultrasound to identify a variety of potential life-threatening conditions such as tubal pregnancies, high risk pregnancies, trauma injuries such as bleeding in the chest and abdomen, advanced heart failure, fluid in the lungs, abdomen and hearts of AIDS patients, and blood clots, to name a few.

Supervised practice makes perfect, so trainees then received ongoing 1:1 bedside scanning practice with expert PURE/MGH trainers every 6 weeks for the duration of the project. Input from trainers and structured assessments of skill retention – also done every 6 weeks-showed that our 18 clinician trainees are amazing! Despite tremendous clinical work loads, their ongoing commitment and enthusiasm to point of care ultrasound was inspiring!

They share stories already of patient lives saved because they used their new POC ultrasound skills. ‘Joseph’ is a 24 year old male with shortness of breath after a fall from a motorcycle. He came to the hospital critically ill. Clinicians were extremely concerned about his breathing status and, in particular, for perforated lungs. Time was of the essence and x-ray unavailable. Bedside ultrasound showed that both lungs were collapsed, a life threatening condition. A tube was placed in each lung and the patient survived and discharged home smiling one week later.

Another patient, ‘Peter’, is 38 years old with AIDS. He was admitted to the medicine team also unstable and unable to breathe well, the reason for which was unknown. The patient did not improve with typical management. A bedside ultrasound was done because the clinicians were perplexed. This ultrasound showed an enormous amount of fluid surrounding the patient’s heart: a life threatening condition for this patient. Because of this ultrasound finding the patient underwent removal of the fluid and survived. These are just two of the success stories rapidly accumulating since the PURE/MGH trainings began 6 months ago!

At the completion of the phase 1 course, along with enormous smiles and hugs from our new colleagues and trainee friends at MUST, 2 questions were repeatedly asked: “When are you coming back? And when can we learn even more?”

With the financial assistance from gracious donors world-wide we hope to return to MUST throughout 2015 and not only continue current training efforts with our initial group of clinicians, but also expand efforts to include more extensive ultrasound-in-trauma training and obstetric training, and a train-the-trainers course for our sono-stars of course!

An enormous thank you to everyone who made this initial effort a huge success AND to those who may contribute in the near future!

This fall has marked a very busy time for PURE with members of our ever-growing team scanning and teaching ultrasound in Ethiopia, Uganda, Rwanda and Liberia simultaneously!

In October and early November we had residents and fellows, Drs. Phindi Chowa, Kenn Ghaffarian and Mike Rubin join the team. They worked with our Rwanda programs coordinator Dr. Paul Pageau and made good progress with our large training cohort in Kigali. Paul and one of our top Rwandan PURE trainers, Dr. Gabin Mbanjumucyo, then travelled to represent PURE teaching at the ultrasound pre-congress for the African Federation of Emergency Medicine conference. Gabin was elected as Rwanda’s representative for the newly formed African Ultrasound Committee, and PURE’s President Dr. Trish Henwood will serve as International Advisor to the Committee.

In the meantime, Drs. Katie O’Brien and Lisa Bebell were busy in Mbarara, Uganda continuing to work with our first group of trainees from a cross-section of specialties at Mbarara Regional Referral Hospital who have been making great process! Late November found PURE leaders Drs. Megan Leo and Dave Mackenzie joining Paul and veteran sonographer David Adams in Kigali to lead our second annual train-the-trainer course as we continue to help build skills and contribute to local teaching capacity.

Trish was across the continent in West Africa, and grateful to secure a Micromaxx generously donated to PURE by Sonosite. She was teaching colleagues and using point-of-care ultrasound to assist in the care of the patients she was treating while working clinically at an Ebola Treatment Unit in northern Liberia with International Medical Corps. She found there were many ultrasound findings that helped patient management and give a better idea of pathophysiology, and she is hoping to return to the region to continue the work soon.

#GivingTuesday is a great opportunity to support PURE’s important and broad-reaching work planned for 2015 and beyond. Please contact us if you have interest in getting more involved with our work.

It’s been a busy week of ultrasound education for PURE staff and trainees. Resident physicians who have been learning point-of-care ultrasound with PURE trainers changed roles this week and have done a fantastic job putting on beginner ultrasound courses for 4th year medical students. The residents participated in a train-the-trainers course this week at Centre Hospitalier Universite Kigali (CHUK), one of Rwanda’s main teaching hospitals. The train-the-trainers course provided the residents with a chance to learn approaches to teaching ultrasound at the bedside, as well as to learn some of the skills and steps required to put on an ultrasound course.
The residents did an outstanding job teaching over 100 medical students this week, delivering lectures and hands-on education to introduce physics and instrumentation, the FAST exam, and echocardiography. The response from the medical students has been overwhelmingly positive as they anticipate beginning their internships next year, and course evaluations have been filled with enthusiastic requests for additional training.
The residents have also had the chance to learn some advanced ultrasound skills with PURE trainers, including volume status assessment, nerve blocks, and vascular access. We’ve had some great scanning sessions on the wards and in the ED at CHUK and have made a number of diagnoses for the clinical teams.
Today we’re on the road south to the Centre Hospitalier Universite Butare, where the residents will deliver another course for 40 medical students. We’re looking forward to working with another motivated group of students, and to continue working to improve the skills of residents and students alike.

US training has intensified this week in Rwanda with the addition of 2 new PURE instructors. Welcome to Mike Rubin, Faculty at Beth Israel Hospital and future Fellow in PoCUS at the University of Ottawa. Also new on the Rwandan PoCUS scene is Kenn Ghaffarian from the University of Pennsylvania Emergency medicine program.

In addition to a bedside ultrasound training blitz this week in the ED for residents and GP’s the PURE team went on the road with an introduction to cardiac PoCUS course in Butare on Thursday. The Internal Medicine residents were quick learners as we went from classroom to scanning their patients on the ward. There was opportunity to address their focused clinical questions and further integrate PoCUS into their practise. This proved to be a very effective approach for these trainees. It has been most fascinating working with a wide range of specialists to find the most relevant PoCUS indications for their unique and resource limited work environment.

Kenn Ghaffarian guides Faida, EM resident, to a better image in the ED

On Friday the PURE instructors brought their PoCUS expertise to a Surgery course back at CHUK. PURE joined forces with local faculty surgeons and radiologists to provide a crash course in US guided core needle biopsy for all surgery residents in Rwanda. PURE forces were strong enough this week to continue Internal Medicine PoCUS training while providing crucial instruction at the surgery course. What a great team!

PURE continues to develop quality PoCUS work here in Rwanda.The foundation of building capacity has been the PoCUS education program which has been tailored to the needs of each specialty. As a result, we have identified PoCUS champions in the different specialties.

Each group of specialists are meeting at least once weekly to define objectives, expand skills and learn how to effectively integrate PoCUS into their unique clinical setting. For example, the team of one junior and two senior resident surgeons have already been meeting regularly and then applying eFAST, advanced cardiac, and the RUSH exam to their clinical work. These surgeons are interested, engaged and eager to continue to develop their PoCUS skills.

Internal medicine and Pediatrics have also begun advanced training. The Senior internal medicine residents are meeting weekly with a focus on incorporating PoCUS to expand their physical exam. Pediatrics is a unique mix of faculty and residents, with an initial focus on the pediatric acute care setting. Local faculty, Tim Walker from internal medicine and Samantha Rossman from Pediatrics deserve recognition for helping set up these sessions.

Lastly, ten EM residents are currently undergoing an eFAST credentialing process designed by a collaboration of local EM faculty and PURE faculty. Special thanks to Simon Pulfrey, and the PURE team of Laura Diegelman, Raja Rao, and Colleen Holley for developing a program that is currently being executed. The EM residents are now benefiting from an innovative and unique approach to credentialing in a resource-limited environment. It includes OSCE assessment, supervised scanning and an independent log book.

Looking forward: PURE plans to design and conduct a PoCUS course specifically for Doc IV’s before they begin to provide care in the district hospitals. Also on the horizon is collaborating with local faculty to provide PoCUS training to GP’s already practicing at the district hospitals.

September and October have been productive months for PURE work in the land of a thousand hills.

It has been a very busy month in Mbarara, Uganda! We have just wrapped up round 1 of point-of-care ultrasound training at Mbarara University of Science and Technology. With the tag-team efforts of Drs. Lisa, Adeline, Trish, Derek, Julius and Katie, 40+ ugandan clinicians were provided with a hands-on introduction to POC ultrasound. Our trainees included clinicians across specialities, including Surgery, Medicine, Pediatrics and Obstetrics. Machines graciously donated by Sonosite are now on-site and available to clinicians. Logistics of training such a large crew has been exciting and challenging: take a look at the cage we had built for our ED machine! The enthusiasm of our new Ugandan friends and trainees is fabulous and we look forward to ongoing collaboration in the upcoming months.

…And the East African trainings go on! Last week PURE officially embarked on a longitudinal point-of-care ultrasound training project in Mbarara, Uganda. Phase 1 of the training is in collaboration with Massachusetts General Hospital (MGH) Department of Emergency Medicine and MGH Center for Global Health. Last March, Trish visited Mbarara Regional Referral Hospital and during her needs assessment recognized that imaging services- ultrasound included – are desperately needed. Most notable at that time was the lack of access to obstetric ultrasound services for pregnant patients. With over 30 babies delivered daily, lack of prenatal ultrasonography is tragic. The obstetrics department was immediately identified as our first ultrasound priority for educational efforts. Further investigation revealed that access to radiography and CT services are highly unpredictable due to frequent power-outs and governmental shortages. Our conclusion: all departments at MRRH are in need of and enthusiastic to learn basic point-of-care ultrasound skills. Thus began PURE’s latest ultrasound endeavor!

Over the next six months Dr. Katie O’Brien will be coordinating and overseeing the trainings in Mbarara for PURE. Our efforts kicked off with a 2-day course for pediatric, surgery and medicine residents. Observed clinical skills examinations (OSCEs) for our trainees prior to the course demonstrated that most folks were brand new to ultrasound yet highly motivated and enthusiastic = ideal students! The trainer team included Drs. Derek Harborne (UK emergency medicine based in Mbarara), Julius Mugisha (Head of Radiology at Mbarara University of Science and Technology), Lisa Bebell (MGH infectious disease/critical care), Katie O’Brien and Trish Henwood. We focused on contextually relevant, basic applications such as E-FAST, basic cardiac and evaluation for deep vein thrombosis. After just 2 days of training our 6 resident trainees were scanning like pros! PURE trainers will work individually with all 6 trainees in the upcoming months to ensure competency, as we investing in this group heavily with hopes they will serve as future PURE trainers in Uganda.

Next up was Point-of-Care Obstetric Ultrasound. Trainees were a mixture of obstetric residents, faculty and midwives. The course taught by Drs. Katie, Julius, Lisa and Adeline Boatin (MGH ob-gyn/global health) focused on FAST and basic antenatal ultrasound. Another 2 day course was undertaken and 14-16 ultrasound disciples born! Similar to the non-ob trainers, we have worked with department leadership to identify 8 of these trainees to be our focus with whom our trainers will work individually through January 2015. We anticipate that with longitudinal skill development, they can become fabulous obstetric sonographers and future PURE trainers at MRRH.

PURE thanks all trainers and trainees for a wonderful first week of ultrasound training in Uganda!